Diagnosis of Heart Failure in Adults

STEVEN A. DOSH, M.D., M.S., OSF Medical Group, Escanaba, Michigan

Heart failure is a common, progressive, complex clinical syndrome with high morbidity and
mortality. Coronary artery disease is its most common cause. The evaluation of symptomatic
patients with suspected heart failure is directed at confirming the diagnosis, determining the
cause, identifying concomitant illnesses, establishing the severity of heart failure, and guiding
therapy. The initial evaluation should include a focused history and physical examination, a
chest radiograph, and an electrocardiogram. The presence of heart failure can be confirmed by
an echocardiogram. Heart failure is highly unlikely in the absence of dyspnea and an abnormal
chest radiograph or electrocardiogram. Radionuclide angiography or contrast cineangiography
may be necessary when clinical suspicion for heart failure is high and the echocardiogram is
equivocal. Patients with confirmed heart failure should undergo additional testing, including a
more detailed history and physical examination; a complete blood count; blood glucose measure-
ment; liver function tests; serum electrolyte, blood urea nitrogen, and creatinine measurements;
lipid panel; urinalysis; and thyroid-stimulating hormone level. A serum ferritin level, human
immunodeficiency virus test, antinuclear antibody assays, rheumatoid factor test, or metaneph-
rine measurements may be required in selected patients. Patients with coronary artery disease,
hypertension, diabetes mellitus, exposure to cardiotoxic drugs, alcohol abuse, or a family history
of cardiomyopathy are at high risk for heart failure and may benefit from routine screening. (Am
Fam Physician 2004;70:2145-52. Copyright© 2004 American Academy of Family Physicians.)

H
See page 2152 for
definitions of strength-of-
recommendation labels.
This article exem-
plifies the AAFP 2004
Annual Clinical Focus on
caring for America’s aging
population.
eart failure is characterized by
an inability of the myocardium
to deliver sufficient oxygenated
blood to meet the needs of tissues
and organs during exercise or at rest. Because
diagnostic criteria for this clinical syndrome
remain ill defined, the actual prevalence is
difficult to determine. Heart failure is esti-
mated to affect 2 to 4.5 million persons in
the United States.1-3 The condition is more
common in men than in women, and its
prevalence increases with age (1.1 percent
in persons 25 to 54 years of age, 3.7 percent
in persons 55 to 64 years, and 4.5 percent
in persons 65 to 74 years).3 Heart failure is
becoming increasingly common as the U.S.
population ages and survival rates after acute
myocardial infarction increase.
The annual direct medical cost of car-
ing for patients with heart failure is esti-
mated to exceed $10 billion.4 Furthermore,
heart failure is a progressive condition: once
symptoms appear, subsequent morbidity
and mortality are high. In patients with
heart failure identified by careful screening,
five-year survival rates are only 59 percent in
men and 45 percent in women.5
This article focuses on the diagnosis of
heart failure from an evidence-based per-
spective. A clinical review6 published in this
issue examines the treatment of heart failure
and the prognosis for affected patients.
Pathophysiology of Heart Failure
Normal myocardial function requires suf-
ficient nutrient-rich, toxin-free blood at rest
and during exercise; sequential depolariza-
tion of the myocardium; normal myocardial
contractility during systole and relaxation
during diastole; normal intracardiac volume
before contraction (preload); and limited
resistance to the flow of blood out of the
heart (afterload). The capacity of the heart
to adapt to short-term changes in preload or
afterload is remarkable, but sudden or sus-
tained changes in preload (e.g., acute mitral
regurgitation, excessive intravenous hydra-
tion), afterload (e.g., aortic stenosis, severe
uncontrolled hypertension), or demand (e.g.,
increased demand because of severe anemia
or hyperthyroidism) may lead to progres-
sive failure of myocardial function. Asympto-
matic dysfunction progresses steadily to overt
heart failure.

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 TABLE 1
Causes of Heart Failure
Common
Coronary artery disease
Hypertension
Idiopathic
Less common
Diabetes mellitus
Valvular disease
Rare
Anemia
Connective tissue disease
Viral myocarditis
Hemochromatosis
Human immunodeficiency virus infection
Hyperthyroidism, hypothyroidism
Hypertrophic cardiomyopathy
Infiltrative disease (including amyloidosis and sarcoidosis)
Mediastinal radiation
Peripartum cardiomyopathy
Restrictive pericardial disease
Tachyarrhythmia
Toxins (including drugs and alcohol)
Trypanosomiasis (Chagas’ disease)
Coronary artery disease accounts for nearly 70 percent
of all cases of heart failure.7 Less frequent causes include
diabetes mellitus and valvular heart disease (Table 1).
Heart failure also can be multifactorial. For example,
the disease can result from acute myocardial infarction
(loss of myocardial contractility) with papillary muscle
dysfunction (increased preload) and acute pulmonary
edema (hypoxemia).
Heart failure may be classified into six types based
on the role of diastolic or systolic dysfunction (Table 2).
Diastolic dysfunction is heart failure caused by compro-
mised myocardial relaxation in the presence of normal
myocardial contractility and ejection fraction. It is asso-
ciated most commonly with coronary artery disease,
The Author
STEVEN A. DOSH, M.D., M.S., has a rural primary care practice
with OSF Medical Group, Escanaba, Mich. He also is associate
professor in the College of Human Medicine at Michigan State
University, East Lansing, where he earned his medical degree. Dr.
Dosh completed an internal medicine residency at Mary Imogene
Bassett Hospital, Cooperstown, N.Y., and a family medicine
residency at Mid-Michigan Regional Medical Center, Midland. In
addition, Dr. Dosh earned a master’s degree in epidemiology from
Michigan State University.
Address correspondence to Steven A. Dosh, M.D., M.S., OSF
Medical Group, 3409 Ludington, Escanaba, MI 49829 (e-mail:
doshstev@msu.edu). Reprints are not available from the author.
2146 American Family Physician
hypertension, aging, and infiltrative cardiomyopathy.
Systolic dysfunction is caused by impaired myocardial
contractility and low ejection fraction. It is associated
most often with coronary artery disease (especially
myocardial infarction), idiopathic dilated cardiomyopa-
thy, hypertension, and valvular disease.
The five types of heart failure resulting from systolic
dysfunction include high output heart failure, low car-
diac output syndrome, right heart failure, left heart fail-
ure, and biventricular failure. High output heart failure
occurs when the demand for blood exceeds the capacity
of an otherwise normal heart to meet the demand. This
type of heart failure may occur in patients with severe
anemia, arteriovenous malformations with shunting of
blood, or hyperthyroidism. Patients with low cardiac
output syndrome have fatigue and loss of lean muscle
mass as their most prominent symptoms, but they
also may have dyspnea, impaired renal function, or
altered mental status. Right heart failure is character-
ized by peripheral edema, whereas left heart failure is
characterized by pulmonary congestion. Both systemic
and pulmonary congestion are present in patients with
biventricular heart failure.
Although the symptoms, causes, prevalence, and epi-
demiology of the six different types of heart failure are
somewhat different, there is substantial overlap, and
types may coexist. Therefore, this review presents an
approach to diagnosis that is appropriate regardless of
the type or cause of heart failure.
Overview of Diagnosis
The spectrum of patients who may be suspected of hav-
ing heart failure ranges from those who are asympto-
matic but at high risk for heart failure (i.e., patients who
abuse alcohol or have coronary artery disease, hyperten-
sion, diabetes mellitus, exposure to cardiotoxic drugs, or
familial history of cardiomyopathy) to those with florid
signs and symptoms of heart failure.
Guidelines from the American College of Cardiology
and the American Heart Association8 identify four stages
in the progression of heart failure. Patients in stage A
have no structural abnormalities but are at high risk for
heart failure. In stage B, patients are asymptomatic but
have structural heart disease. Patients in stage C have
structural abnormalities and past or present heart fail-
ure. In stage D, patients have end-stage heart failure and
require mechanical circulatory support, infusion of ino-
tropic agents, cardiac transplantation, or hospice care.
The presence of asymptomatic patients, the progres-
sive nature of heart failure, the high morbidity and mor-
tality rates associated with the condition, and the fact
www.aafp.org/afp Volume 70, Number 10 � November 15, 2004
 Diagnosis of Heart Failure
TABLE 2
Classification of Heart Failure

Type Characteristics
Diastolic dysfunction Normal myocardial contractility, left
ventricular volume, and ejection
fraction; impaired myocardial
relaxation; diminished early
diastolic filling
Systolic dysfunction Absolute or relative impairment
of myocardial contractility, low
ejection fraction
High output heart Bounding pulses, wide pulse
failure pressure, accentuated heart
sounds, peripheral vasodilatation,
increased cardiac output and
ejection fraction, moderate four-
chamber enlargement
Low cardiac output Fatigue, loss of lean body mass,
syndrome prerenal azotemia, peripheral
vasoconstriction, reduced left or
right contractility
Right heart failure Dependent edema, jugular venous
distention, right atrial and
ventricular dilatation, reduced
right-sided contractility
Left heart failure Dyspnea, pulmonary vascular
congestion, reduced left-sided
contractility
Biventricular failure Dyspnea, dependent edema,
jugular venous distention,
pulmonary vascular congestion,
bilateral reduced contractility
that early treatment can delay the onset of overt heart
failure have caused some investigators to speculate about
the need to screen patients for heart failure.9 Screening
of the general population currently cannot be recom-
mended.10 However, screening echocardiography may
be appropriate in selected patients who are at high risk
for developing systolic dysfunction, such as patients with
a strong family history of cardiomyopathy and patients
with exposure to cardiotoxic drugs.8
The evaluation of symptomatic patients with sus-
pected heart failure is directed at confirming the pres-
ence of heart failure, determining the cause, identifying
comorbid illnesses, establishing the severity of heart
failure, and guiding therapy. The first four purposes of
the evaluation are discussed in this article. Therapy is
reviewed in another article.6
Confirming the Presence of Heart Failure
Heart failure is a clinical diagnosis, and no single test
can establish its presence or absence. In patients with
this condition, the most frequent clinical findings are
related to decreased exercise tolerance or fluid reten-
tion11 (Table 3).12-15 Decreased exercise tolerance typically
presents as dyspnea or, much less commonly, fatigue
on exertion. Fluid retention results in orthopnea, rales,
elevated jugular venous pressure, dependent edema,
and the typical radiographic findings of cardiomegaly,
pulmonary edema, and pleural effusion. Unfortunately,
there currently are no validated clinical decision rules
to estimate the contribution of each of these findings to
heart failure.
Nearly all patients with heart failure present with
dyspnea. The absence of dyspnea makes heart failure
highly unlikely (sensitivity: greater than 95 percent), and
other explanations for the patient’s symptoms should be
sought first.
It is important to note that heart failure is present in
only about 30 percent of patients who present with dysp-
nea in the primary care setting.16 Other common causes
of dyspnea in adult primary care patients include asthma
(33 percent), chronic obstructive pulmonary disease (9
percent), arrhythmia (7 percent), infection (5 percent),
interstitial lung disease (4 percent), anemia (2 percent),
and pulmonary embolism (less than 2 percent).16 There-
fore, 30 percent is a reasonable pretest estimate of the
probability of systolic or diastolic heart failure in patients
presenting with dyspnea in the primary care setting.
In patients with dyspnea, a focused history and physical
examination, combined with selected diagnostic testing,
can identify heart failure (Figure 1).8,12-14 This diagnostic
approach, which avoids unnecessary testing and expense,
is guided by the sensitivity and specificity (or likelihood
ratios) of various clinical findings12-14,17 (Table 3).12-15
A history of myocardial infarction is of limited assis-
tance in the diagnosis of heart failure. A positive history
only slightly increases the probability of heart failure, and
a negative history is associated with only a small decrease
in probability. Likewise, dependent edema provides min-
imal help in diagnosing heart failure. If present, hepato-
jugular reflux increases the likelihood of heart failure
moderately; absence of this finding does little to reduce
the likelihood of heart failure.12,17 Heart failure can be
ruled in if jugular venous distention, displacement of
cardiac apical pulsation, or a gallop rhythm is present
(specificity: 95 percent or greater); however, absence of
these findings is of limited help in ruling out heart fail-
ure. It is important to note that the ability to detect physi-
cal findings of heart failure depends on proper technique
and the skill of the examiner (Table 4).17
A chest radiograph and an electrocardiogram should
be obtained in patients with dyspnea and suspected heart
failure. A normal chest radiograph slightly decreases the
probability of heart failure and helps identify pulmonary

November 15, 2004 � Volume 70, Number 10 www.aafp.org/afp American Family Physician 2147
 TABLE 3
Sensitivity, Specificity, and Likelihood Ratios for Selected Clinical Findings in Detecting
LV Dysfunction in Patients with Suspected Heart Failure

Positive Negative
Sensitivity Specificity likelihood ratio likelihood ratio
Clinical finding Reference standard (%) (%) (95 percent CI) (95 percent CI)

History
Dyspnea on LV dysfunction on 100 17 1.2 (1.1 to 1.3) 0 (0 to 0.1)
exertion echocardiogram
Paroxysmal nocturnal LV dysfunction on 39 80 2.0 (1.2 to 3.1) 0.8 (0.6 to 1.0)
dyspnea echocardiogram
Previous myocardial LV dysfunction on 59 86 4.1 (2.7 to 6.2) 0.5 (0.3 to 0.7)
infarction echocardiogram
Physical examination
Displaced LV dysfunction on 66 95 16.0 (8.1 to 31.0) 0.4 (0.2 to 0.6)
cardiac apex echocardiogram
Dependent LV dysfunction on 20 86 1.4 (0.7 to 2.9) 0.9 (0.8 to 1.1)
edema echocardiogram
Gallop rhythm LV dysfunction on 24 99 27.0 (6.1 to 120.0) 0.8 (0.6 to 0.9)
echocardiogram
Hepatojugular Clinicoradiographic 33 94 6.0 (1.3 to 29.0) 0.7 (0.5 to 1.1)
reflux score
Jugular venous LV dysfunction on 17 98 9.3 (2.9 to 30.0) 0.8 (0.7 to 1.0)
distention echocardiogram
Pulmonary LV dysfunction on 29 77 1.3 (0.7 to 2.2) 0.9 (0.7 to 1.1)
rales echocardiogram
Tests
Chest radiograph: LV dysfunction on 71 92 8.9 (2.1 to 83.0) 0.3 (0.2 to 0.6)
cardiomegaly, echocardiogram
pulmonary
edema, or both
ECG: anterior LV dysfunction on 94 61 2.4 (2.1 to 2.8) 0.1 (0 to 0.2)
Q waves or LBBB echocardiogram
BNP level (pg per mL)
≥ 150 Blinded clinical — — 5.0 (4.4 to 5.5) —
assessment by
two cardiologists
100 to 149 As above — — 0.7 (0.6 to 1.0) —
50 to 99 As above — — 0.5 (0.4 to 0.6) —
< 50 As above - - 0.05 (0.03 to 0.06) —

LV = left ventricular; CI = confidence interval; ECG = electrocardiogram; LBBB = left bundle branch block; BNP = B-type natriuretic peptide.
Information from references 12 through 15.

causes of dyspnea. A normal electrocardiogram makes
heart failure unlikely (sensitivity: 94 percent). If both
the electrocardiogram and chest radiograph are normal,
heart failure is highly unlikely (sensitivity: 95 percent or
greater), and other causes should be considered.13,14
Heart failure is strongly suggested by the presence
of cardiomegaly or pulmonary vascular congestion on
the chest radiograph. The probability of heart failure
is increased by anterior Q waves or left bundle branch
block on the electrocardiogram. Therefore, patients
with dyspnea and suggestive abnormalities on the elec-
trocardiogram or chest radiograph should undergo
two-dimensional echocardiography with Doppler flow
studies. The echocardiogram is the diagnostic standard
for identifying both systolic and diastolic heart failure.
Radionuclide angiography or contrast cineangiography
may be helpful if the echocardiogram is equivocal or
technically inadequate.18,19
If the B-type natriuretic peptide (BNP) level is
extremely low (less than 50 pg per mL), heart failure is
highly unlikely. Conversely, a BNP level of 150 pg per mL
or greater is moderately helpful (specificity: 83 percent)

2148 American Family Physician www.aafp.org/afp Volume 70, Number 10 � November 15, 2004
 Evaluation for Heart Failure

Patient with suspected heart failure

Dyspnea present?

Yes No

ECG and chest radiograph Consider other causes.

Abnormal Normal

Echocardiogram Consider other causes.

Normal Abnormal Technically

unsatisfactory

Consider
other causes. Radionucleotide scan
Dilated Diastolic Systolic
cardiomyopathy dysfunction dysfunction

Abnormal Normal

More detailed history, physical, and laboratory testing

• Medical history: anemia, cardiotoxic medications, chest irradiation, collagen vascular Consider other causes.
disease, CAD, diabetes mellitus, hemochromatosis, hypercholesterolemia, hypertension,
infectious disease, peripheral vascular disease, pheochromocytoma, rheumatic fever,
sexually transmitted disease, thyroid disease, valvular heart disease
• Social history: international travel, substance abuse (alcohol, drugs)
• Family history: CAD, cardiac conduction abnormality, cardiomyopathy, skeletal myopathy,
sudden death
• Physical examination: abnormal deep tendon reflexes, bradycardia or tachycardia, bronze skin,
cardiac arrhythmia, dependent edema, diminished peripheral pulses or arterial bruits, displaced
cardiac apex, elevated blood pressure, heart murmur, hepatomegaly or hepatojugular reflux,
joint inflammation, jugular venous distention, pallor, pericardial rub, pulmonary rales, third
heart sound, thyromegaly or thyroid nodule, weight loss or gain
• Laboratory tests: antinuclear antibodies and rheumatoid factor (if connective tissue disease is
suspected), complete blood count, liver and kidney function tests, HIV screening (in high-risk
patient), metanephrines (if pheochromocytoma is suspected), thyroid-stimulating hormone,
serum electrolytes and lipid panel, serum ferritin (if hemochromatosis is suspected), urinalysis,
viral titers (if patient had recent viral infection)
• Coronary angiography in patient with CAD and angina
• Endomyocardial biopsy in patient with dilated cardiomyopathy and rapidly progressive symptoms

Cause identified?

No Yes

Establish severity. Establish severity.

Treat heart failure. Treat cause.
Treat comorbid conditions. Treat heart failure.
Treat comorbid conditions.

Figure 1. Suggested approach to the patient with suspected heart failure. (ECG = electrocardiogram; CAD = coronary
artery disease; HIV = human immunodeficiency virus)
Information from references 8 and 12 through 14.

November 15, 2004 � Volume 70, Number 10 www.aafp.org/afp American Family Physician 2149

TABLE 4
Techniques for Eliciting Physical Findings
in Patients with Suspected Heart Failure
Physical finding Technique
Abdominojugular Patient position: supine, so that the
reflux top of the jugular venous pulsation is
seen in the right side of the neck
Encourage the patient to relax and
breathe normally. Apply firm steady
pressure (25 to 30 mm Hg) to the
midabdomen for 30 seconds. The
test is positive if there is a sustained
(≥ 10-second) 4-cm rise in the
venous pressure.
Displaced cardiac Patient position: supine or 45-degree-
apex angle left lateral decubitus
Palpate the fourth and fifth left
intercostal space during expiration.
The test is positive if the impulse is
outside the midclavicular line.
Gallop rhythm Patient position: 45-degree-angle left
lateral decubitus
Listen with the bell of the stethoscope
lightly applied to the chest wall.
Jugular venous Patient position: supine at 45-degree
distention angle, with head turned to the right
Perform this test in a well-lit room.
Adjust the incline of the bed until
the top of venous pulsation is visible
above the angle of the jaw. Measure
the distance to the level of the angle
of Louis.
Information from reference 17.
in ruling in heart failure15 (Table 3).12-15 However, the
independent contribution of BNP to the diagnosis of
heart failure has not been determined, and further stud-
ies are required to delineate the role that this peptide
should play in the diagnosis of heart failure.
The diagnosis of diastolic dysfunction is problematic.
Diagnostic criteria for this type of heart failure are
poorly defined, diastolic dysfunction often is present in
patients who also have left ventricular systolic dysfunc-
tion, and most patients with diastolic dysfunction have
other conditions that could explain their symptoms.20,21
Currently, Doppler echocardiography is the primary tool
for identifying abnormal diastolic function, including
diminished early diastolic filling and reduced ventricu-
lar compliance associated with diastolic dysfunction.22
2150 American Family Physician www.aafp.org/afp
Identifying Causes and Comorbidities
of Heart Failure
Individually or in combination, myocardial, valvular,
pericardial, and systemic diseases may cause heart
failure (Table 1). As previously noted, heart failure can
result from increased demand, systolic dysfunction, or
diastolic dysfunction. Heart failure with normal left
ventricular systolic function must be distinguished from
respiratory disease, obesity, and myocardial ischemia.20
The history, physical examination, and laboratory
evaluation may provide clues to the type of heart failure,
its cause, and any comorbidities (Table 5). The Doppler
echocardiogram can identify systolic and diastolic dys-
function, and it may identify valvular stenosis or insuf-
ficiency, cardiomyopathy, or pericardial disease.
Even if the echocardiogram identifies the cause of
heart failure, a broad spectrum of illnesses may exacer-
bate the condition. Therefore, the initial evaluation of
patients with confirmed heart failure must identify con-
comitant illnesses as well as the primary cause (Figure
1).8,12-14 This evaluation also may identify patients who
require additional testing, such as a serum ferritin mea-
surement, viral titers, a human immunodeficiency virus
test, antinuclear antibody assays, a rheumatoid factor
test, or metanephrine measurements.8 Rarely, patients
may require coronary angiography or endomyocardial
biopsy.8
Establishing the Severity of Heart Failure
The severity of heart failure at the time of initial diagnosis
is helpful in determining prognosis, monitoring disease
progression, and evaluating response to treatment.
In symptomatic patients, the level of exertion required
to cause symptoms reflects the degree of myocardial
impairment, but it is important to recognize that the
correlation between cardiac function and symptoms is
not strong. Nevertheless, symptoms are the basis of the
New York Heart Association (NYHA) classification of
heart failure, which often is used to determine prog-
nosis.23 In NYHA class I heart failure, symptoms occur
with greater than ordinary physical activity. Patients
with NYHA class II heart failure have symptoms with
ordinary physical activity. In NYHA class III heart fail-
ure, symptoms occur with minimal physical activity.
Patients with NYHA class IV heart failure have symp-
toms while at rest.
The ejection fraction (as measured by the echocar-
diogram) and the six-minute walk test independently
predict mortality in patients with left ventricular dys-
function. The six-minute walk test is performed by hav-
ing the patient walk a 30.48-m (100-ft) course 15.24 m
Volume 70, Number 10 � November 15, 2004
 TABLE 5
Implication of Selected Clinical and Laboratory Findings in Patients with Heart Failure

Clinical finding Implication

History
Fatigue Low cardiac output syndrome
Nausea or abdominal pain Hepatic congestion resulting from right
ventricular dysfunction
Alcohol use, anemia, cardiotoxic medications, chest irradiation, connective tissue Cardiomyopathy
disease, exposure to cardiotoxic medications, exposure to sexually transmitted
disease (e.g., human immunodeficiency virus infection), hemochromatosis,
hyperthyroidism, hypothyroidism, infectious diseases, pheochromocytoma
Chest irradiation, connective tissue disease, previous open Restrictive pericarditis
heart surgery
Coronary artery disease, diabetes mellitus, hypercholesterolemia, hypertension, Coronary artery disease
peripheral vascular disease, tobacco use
Physical examination
Abnormal deep tendon reflexes, bradycardia or tachycardia, bronze skin, joint Cardiomyopathy
inflammation, pallor, thyromegaly or thyroid nodule
Ascites, dependent edema, hepatomegaly, hepatojugular reflux, jugular venous Right ventricular dysfunction
distention, weight gain
Cool extremities, cyanosis, weight loss Low cardiac output syndrome
Diminished peripheral pulses or arterial bruits Coronary artery disease
Displaced cardiac apex, pulmonary rales, pulse rate higher than 90 beats per Left ventricular dysfunction
minute, systolic blood pressure below 90 mm Hg, third heart sound
Heart murmur Valvular heart disease
Laboratory tests
Anemia, abnormal thyroid-stimulating hormone level Cardiomyopathy
Elevated blood urea nitrogen and creatinine levels Low cardiac output syndrome
Elevated liver function values Hepatic congestion resulting from right
ventricular dysfunction
Hyperglycemia, hyperlipidemia Coronary artery disease

(50 ft) in each direction in a hall, with a chair positioned

TABLE 6
Clinical Implications of the Six-Minute Walk Test
The rightsholder did not grant rights to reproduce
this item in electronic media. For the missing item,
see the original print version of this publication.
at each end of the course) for six minutes. The patient is
allowed to stop and rest as often as desired but is encour-
aged to continue walking. After six minutes, the total
distance walked is measured and recorded to the nearest
meter or foot. The distance walked correlates well with
subsequent hospitalization and death (Table 6).24 This
simple test also may be helpful in monitoring disease
progression and response to treatment.
In routine clinical settings, the 35 percent five-year
mortality rate among all patients with newly diagnosed
heart failure is about 50 percent higher in patients with
NYHA class III or IV heart failure.11 The one-year mor-
tality rate increases by about 75 percent for every 15 per-
cent drop in ejection fraction and by about 50 percent
for each 120-m (394-ft) decrease in the distance walked
on the six-minute walk test.

November 15, 2004 � Volume 70, Number 10 www.aafp.org/afp American Family Physician 2151
 Strength of Recommendations

Key clinical recommendation Levels References

Screening the general population for heart failure is not recommended, but screening high-risk C 8
patients may be appropriate.
The initial evaluation of patients with suspected heart failure should include a focused history and C 8
physical examination, an ECG, and a chest radiograph. An echocardiogram can confirm the diagnosis.
Dependent edema and pulmonary rales are of limited value in diagnosing heart failure resulting from B 12, 14
left ventricular dysfunction.
Heart failure can be ruled in if jugular venous distention, displacement of the apical pulsation, or a B 12
gallop rhythm is present.
Absence of dyspnea or a normal ECG and chest radiograph make the diagnosis of heart failure highly B 12, 13, 14
unlikely.
If heart failure is confirmed by an echocardiogram, a more detailed history and physical examination, C 8
a complete blood count, blood glucose level, liver function tests, serum electrolyte levels, serum lipid
panel, blood urea nitrogen level, creatinine level, urinalysis, and thyroid-stimulating hormone level
should be obtained.

ECG = electrocardiogram.

The author indicates that he does not have any conflicts of interest.
Sources of funding: none reported.
This article is one in a series developed in collaboration with the
American Heart Association. Guest editor of the series is Sidney C. Smith,
Jr., M.D., Chief Science Officer, American Heart Association, Dallas.
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2152 American Family Physician www.aafp.org/afp Volume 70, Number 10 � November 15, 2004